Hospital Policy Manual

Policy Number: 8.1

Effective Date: 7/01/12

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER

- SHREVEPORT
PHARMACY SERVICES
Purpose:
To establish responsibility for drug distribution and appropriate drug therapy for both
inpatient services and the outpatient clinics within the guidelines of State & Federal
Regulations, Joint Commission and standards of practice.
Policy:
1.

Pharmacy

Location

Hours

Telephone

Central Pharmacy AG-13

24 hours daily

675-5175

Feist-Weiller
Cancer Center
Satellite

8am-4:30pm M-F

813-1500

ACC Pharmacy
1606 Kings Hwy
Shreveport, LA

8am-4:30pm M-F

813-1815

Research Pharmacy B-134

8am-4:30pm M-F

813-1197

B-410

2. Pharmacy Services shall be responsible for responsive and accurate drug storage,
distribution, appropriate and safe usage of drugs, inventory control, budget, patient
billing for medications and all policies and procedures regarding such activities.
Select Department specific policies regarding medication distribution, administration
and control shall be submitted to the P&T Committee for review prior to initiation.
The pharmacy shall review all non-emergent/non-urgent medication orders prior to
administration.
3. Drugs stocked in the hospital
a. Only drugs approved for inclusion in the United States Pharmacopoeia, National
Formulary, New Drugs or Accepted Dental Remedies, or which are approved by
the Hospitals P&T Committee, shall be eligible for use in the Hospital. Drugs
requested by members of the Medical/Dental staff not listed in the above
compendia, or not yet evaluated by the P&T Committee shall be obtained and
considered tentatively approved only if the request is signed by the department

Hospital Policy Manual

Policy Number: 8.1
Effective Date: 7/01/12

head or service chief. Tentatively approved drugs shall be submitted to the P&T
Committee for evaluation at the next scheduled meeting.
b. Drug products classified by the FDA as ineffective will not be stocked by the
Hospital Pharmacy; possibly effective drugs may be obtained at the individual
physicians discretion.
c. The Pharmacy shall be responsible for informing the appropriate physician and
nursing unit if a drug or dosage form is not immediately available.
d. LSUHSC Pharmacy will substitute generic equivalents of brand name drugs
ordered. If the physician has reasons to believe the generic drug is not
equivalent, such information should be documented and forwarded to the
Pharmacy.
e. Pharmacy will not purchase over-the-counter non-formulary medications.
4. Compounding of Items
a. In situations where drugs not commercially available are widely used based on
literature reports and where there exists a recipe for the preparation of these
products, Pharmacy will prepare them when possible.
b. If a recipe is not available or if the product is to be made from non-sterile drugs
or impure chemicals, the prescriber will submit a completed non-formulary
request and the P&T Committee (or P&T Committee Chairperson/Medical
Director in an emergent situation) will review the feasibility of Pharmacy mixing
these products on an individual basis.
5. Drug packaging and Labeling
The Pharmacy Service shall be responsible for the proper packaging and labeling of
all drugs or chemicals dispensed by the Pharmacy for use in patient treatment.
Labels used by the Pharmacy shall be distinctive and not used by other Hospital
departments.
All medications shall be labeled with:

Drug name, strength and amount (if not apparent from the container),
Expiration date when not used in 24 hours,
Expiration time when expiration occurs in less than 24 hours
For all compounded IV admixtures and parenteral nutrition solutions, the
date prepared, the diluents preparing, and the pharmacist initials,
Patient name
Patient location

Hospital Policy Manual

Policy Number: 8.1
Effective Date: 7/01/12

Directions for use and applicable cautionary statements either on the

label or attached as an accessory label (example: requires
refrigeration or for IM use only)

______________________
Administrator

_____6/22/12___________
Date

Approved by Clinical Board: June 2000, 4/17/01, 2/17/04, 2/20/07, 6/19/12

Written 3/95
Reviewed: 11/97, 12/06, 6/12
Revised: 2/01, 1/04, 12/06, 6/12
Combined 8.1, 8.1.4, 8.1.1, 8.1.3 and 2 new (1/29/04)